AH Patient Encounter

Adriana Hernandez’s Assessment
Adriana Hernandez is a 64-year-old woman presenting with acute-onset dyspnea, dry cough, low-grade fever, and pre syncopal symptoms. Heart and lung auscultation is normal; she is found to be hypoxic (O2 saturation 90% on room air). Past medical history is significant for diabetes mellitus, hypertension, tobacco abuse, and obesity. She has a family history of coronary artery disease.
Her social history reveals she is a Spanish teacher who emigrated from Mexico. She drinks 4 to 5 glasses of wine a week and smokes 2 packs a day. Her diet is rich with rice, chicken, fish, and beans. She tries to avoid sweets but cheats once a week.
AH was presented in the Urgent Care with acute-onset dyspnea, dry cough, diaphoretic skin, a little lightheadedness, low grade fever. Short of breath upon exertion and rest. She has a normal heart and lung exam, but has bilateral lower leg edema, and RIGHT CALF tenderness. Of note is a RIGHT knee replacement 6 weeks prior and a past medical history for obesity, Diabetes Mellitus, 2 packs per day smoking habit and a sedentary lifestyle since surgery. Patient smokes 2 packs per day for 30 years now, was offered Smoking Cessation from prior visits but non- compliant. Her father has history of MI, Heart Failure, Mother has history of CVA, Diabetes. She also has a family history of Coronary Artery Disease (CAD).
AH is also obese (5’3” and 200 lbs), non compliant ddiet (eats lots of rice, beans, chocolates, sweets, even though she is diabetic. Patient has no exercise in lifestyle even though was recommended to lose weight.

1. Evaluate lab results to determine the actual and/or potential diseases for which patient is at risk (SEE LAB RESULTS), PLEASE REFER TO UPLOADED GRADING CRITERIA AS WELL.
2. Explain history and physical assessment results that contribute to AH’s risk.
3. Cited lab results correlate with the assessment findings to help determine risk

AH Test Results:

Name
Value
Units
Reference Range

Brain natriuretic peptide (BNP)
2.1
µg/L
<3.1

CBC:

Name
Value
Units
Reference Range

White blood cells (WBCs)
6,943
mm3
4,000-10,000
Red Blood Cell Count (RBC)
5.3
million/µl
4.5-5.9(?), 4.0-5.2(?), adults
Hemoglobin (Hgb)
16
g/dl
14-18(?), 12-16(?), adults
Hematocrit (Hct)
47
%
42-54(?), 37-47(?), adults
Mean corpuscular volume (MCV)
99
fl
82-103, adults
Mean corpuscular hemoglobin (MCH)
34
µm3
26-34, adults
Mean corpuscular hemoglobin concentration (MCHC)
33
%
30-37, adults
Platelets (thrombocytes)
378
k/dL
150-399, adults
Red cell distribution width (RDW)
14.1
%
11.5-14.5, adults
Neutrophils
63
%
46-78, adult
Lymphocytes
22
%
18-52, adult
Monocytes
6
%
3-10, adult
Eosinophils
6
%
0-6, adult
Basophils
3
%
0-3, adult
Segmented neutrophils
59
%
36-72, adult
Band Cells
4
%
0-6, adult

BMP:
Name
Value
Units
Reference Range

Sodium (Na+)
141
mmol/L
135-145
Potassium (K+)
4.2
mmol/L
3.5 to 5.1
Chloride (Cl-)
95
mmol/L
95-102(1mo-adult), 91-118(1d-1mo)
Carbon dioxide, total (CO2)
25
mmol/L
22-29(15y-adult), 20-28(1y-15y)
Glucose (BG/Glu)
107
mg/dL
70-110(fasting), 70-200(non-fasting)
Urea nitrogen (BUN)
11
mg/dL
8-21(15y-adult), 5-18(1mo-15y)
Creatinine (Cr)
0.6
mg/dL
0.6-1.3(?), 0.5-1.1(?)
Calcium (Ca2+)
9.7
mg/dL
8.7-10.7(1 mo-adult), 8.7-11.9
*Anion Gap
11
mEq/L
10-20 [(Na+ + K+) – (Cl- + HCO3-)]

Chest x-ray PA:
No acute cardiopulmonary process is seen. No evidence of infiltrates or pneumothorax.
• This chest x-ray (CXR) rules out pneumonia, pneumothorax, and heart failure.
• CXRs typically reveal no acute process in the clinical setting of COPD, unless a COPD flare is caused by pneumonia. In that case, an infiltrate may be seen.
CT pulmonary angiogram (CPTA):
• There are occlusive pulmonary emboli within the left and right main pulmonary arteries. The thrombus within the right main pulmonary artery extends into the right lower lobe segmental arteries The heart is slightly enlarged with enlargement of the ventricle deviating the intraventricular septum indicating right heart strain. Additionally, the main pulmonary artery measures approximately 3.2 cm in diameter, indicating pulmonary arterial hypertension. Lung windows demonstrates patchy consolidation at the right lower lobe peripherally which represents infarcted lung parenchyma. There is a small right-sided pleural effusion. The left lung is clear. There is no evidence of enlarged hilar or mediastinal lymphadenopathy. The visualized portions of the upper abdominal viscera including the adrenal glands are normal. Evaluation of bone windows demonstrate no abnormality.

Name
Value
Units
Reference Range

D-dimer
750
ng/mL
0-300

Name
Value
Units
Reference Range
Troponin I (cTnl)

0.2
ng/mL
<1.5

EKG Interpretation:
The patient exhibits an abnormal ECG. Sinus tachycardia is the most common ECG finding in the setting of pulmonary embolism. However, it is important to remember that sinus tachycardia is nonspecific, and that many conditions that cause hypoxia will cause sinus tachycardia.
Pulmonary embolism less commonly causes a right-heart strain pattern (aka S1Q3T3 pattern); i.e., right bundle branch block, or a deep S wave in lead I, Q wave in lead III; and an, an inverted T wave in lead III.
Summary:
The CT set shows bilateral central pulmonary emboli with right lower lobe pneumonia infarction.
CT pulmonary angiogram has excellent test characteristics (highly sensitive and highly specific); a positive (abnormal) test rules in PE, and a negative test rules it out.

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